1. Management of Morning Hyperglycemia Following Cardiac Surgery LUMC 2ICU CV-Surgical Team CV AnesthesiaNursing Staff Pharmacy StaffAnesthesia Residents LUMC 2ICU CV-Surgical Team CV AnesthesiaNursing Staff Pharmacy StaffAnesthesia Residents

2. Identifying the Problem Current data demonstrates that poor glycemic control in the critically ill/cardiac surgical population leads to poor clinical outcomes even in patients without diabetes.

3. Solutions Implemented Reviewed scientific literature Aggressive education of CV surgery team on insulin protocol PharmD hired for 2ICU with rounding on all patients Implemented new insulin protocol to all cardiac surgery patients to assure tight glycemic control (80-120mcg/dL) Appointed a nurse liaison to the hospital Diabetic Committee Reviewed scientific literature Aggressive education of CV surgery team on insulin protocol PharmD hired for 2ICU with rounding on all patients Implemented new insulin protocol to all cardiac surgery patients to assure tight glycemic control (80-120mcg/dL) Appointed a nurse liaison to the hospital Diabetic Committee

4. Analysis The frequency of hyperglycemia on the morning following cardiac surgery have significantly decreased following the transition from IV to subcutaneous protocol and ICU insulin protocol released initially in LUCI and currently in EPIC

5. Recommendations for Further Study and Action To study if aggressive management of glucose helps decrease wound infections To report incidence of hypoglycemia in the cardiac surgery patient population To study if aggressive management of glucose helps decrease wound infections To report incidence of hypoglycemia in the cardiac surgery patient population

6. Results Morning Glucose Control Following Cardiac Surgery Percent of Cardiovascular Surgery Patients with Morning Normoglycemia These data are confidential and to be used for quality improvement purposes only. Month (number of results) 01/2003 (n=38)02/2003 (n=47)03/2003 (n=37)04/2003 (n=40) 05/2003 (n=44) 06/2003 (n=41) 07/2003 (n=42) 08/2003 (n=32) 09/2003 (n=31) 10/2003 (n=32) 11/2003 (n=30)12/2003 (n=17) 01/2004 (n=31)02/2004 (n=39)03/2004 (n=43)04/2004 (n=33)05/2004 (n=37) 06/2004 (n=41) 07/2004 (n=45)08/2004 (n=45)09/2004 (n=38) 10/2004 (n=40) 11/2004 (n=42) 12/2004 (n=38)01/2005 (n=38) 02/2005 (n=48) 03/2005 (n=45) 04/2005 (n=38) 05/2005 (n=38)06/2005 (n=37)07/2005 (n=43)08/2005 (n=37)09/2005 (n=33) 10/2005 (n=42) 11/2005 (n=35) 12/2005 (n=36) 01/2006 (n=22) 10 20 30 40 50 60 70 UCL = 30.68 Mean = 13.60 Numerator: Number of cardiac surgery patients with a normoglycemic (70mg/dL to 120mg/dL) result on the first glucose drawn on post-operative day 1 between 4AM and 8AM Denominator: All cardiac surgery patients with a valid glucose reading (40-400mg/dL), drawn on post-operative day 1 from 4AM to 8AM Data Source: Clarity database, FORCE database. Analysis: The control chart indicates a statistically significant change (improvement) in morning glycemic control, of cardiac surgery patients on post operative day 1, following the initial protocol transition in April 2004. Confidence limits are based on results prior to initial interventions, from 1/03 through 3/04.

7. Results Morning Glucose Control Following Cardiac Surgery Numerator: Number of cardiac surgery patients with a normoglycemic (70mg/dL to 120mg/dL) result on the first glucose drawn on post-operative day 1 between 4AM and 8AM Denominator: All cardiac surgery patients with a valid glucose reading (40-400mg/dL), drawn on post-operative day 1 from 4AM to 8AM Data Source: Clarity database, FORCE database. Analysis: Morning glycemic control of cardiac surgery patients on post operative day 1 improved from 14% to 43% of patients following protocol implementation.

8. Results Median Morning Glucose Following Cardiac Surgery Definition: Median value of first morning glucose (drawn on post-operative day 1 from 4AM to 8AM) for cardiac surgery patients. Glucose readings below 40mg/dL and above 400mg/dL were excluded. Data Source: Clarity database, FORCE database. Analysis: The control chart indicates a statistically significant change (improvement) in morning glycemic control, of cardiac surgery patients on post operative day 1, following the initial protocol transition in April 2004. Confidence limits are based on results prior to initial interventions, from 1/03 through 3/04.

9. Results Median Morning Glucose Following Cardiac Surgery Glucose (mg/dL) These data are confidential and to be used for quality improvement purposes only. Month of Glucose Result (number of patients) 01/2003 (n=38)02/2003 (n=47) 03/2003 (n=37)04/2003 (n=40)05/2003 (n=44) 06/2003 (n=41) 07/2003 (n=42) 08/2003 (n=32) 09/2003 (n=31)10/2003 (n=32) 11/2003 (n=30) 12/2003 (n=17) 01/2004 (n=31) 02/2004 (n=39) 03/2004 (n=43) 04/2004 (n=33) 05/2004 (n=37) 06/2004 (n=41) 07/2004 (n=45) 08/2004 (n=45) 09/2004 (n=38) 10/2004 (n=40)11/2004 (n=42) 12/2004 (n=38) 01/2005 (n=38) 02/2005 (n=48) 03/2005 (n=45) 04/2005 (n=38) 05/2005 (n=38)06/2005 (n=37) 07/2005 (n=43) 08/2005 (n=37) 09/2005 (n=33)10/2005 (n=42) 11/2005 (n=35) 12/2005 (n=36) 01/2006 (n=22) 100 120 140 160 180 200 UCL = 199.50 Mean = 163.50 LCL = 127.50 UCL = 146.51 Mean = 122.93 LCL = 99.36 Definition: Median value of first morning glucose (drawn on post-operative day 1 from 4AM to 8AM) for cardiac surgery patients. Glucose readings below 40mg/dL and above 400mg/dL were excluded. Data Source: Clarity database, FORCE database. Analysis: Morning glycemic control of cardiac surgery patients on post operative day 1 improved from a median of 164 mg/dL to 123 mg/dL following protocol implementation. The current median value of 123 mg/dL also appears to have decreased from February to September 2005.